Table 2.

Supportive Manometric Measures which may Increase Confidence for a Disorder

Supportive Measure	Protocol	Normal Response
Multiple Rapid Swallow (MRS)	Five swallows of 2‐mL liquid at 2‐3 second intervals	Absence of esophageal body contractility (DCI < 100 mmHg•s•cm) with complete deglutitive inhibition of the LES during MRS and presence of post-MRS contraction augmentation (DCI post MRS greater than single swallow mean DCI).
Rapid Drink Challenge (RDC)	Rapid drink of 200ml of liquid	Absence of esophageal body contractility (DCI < 100 mmHg•s•cm) with complete deglutitive inhibition of the LES during RDC and no evidence of major motility disorder post-RDC.
Solid Test Swallow	Ten swallows of ~1-cm3 soft solid (e.g. bread, soft boiled rice, marshmallow)	Presence of >20% pharyngeal swallows being followed by an effective esophageal contraction defined by DCI > 1000 mmHg•s•cm and without a large break (>5 cm) in the contractile front.
Solid Test Meal (STM)	200g of soft solid meal (e.g. soft boiled rice, bread) ingested at normal rate for patient. Study stopped if STM not completed in 8-min.	Presence of >20% pharyngeal swallows being followed by an effective esophageal contraction defined by DCI > 1000 mmHg-s-cm and without a large break (>5 cm) in the contractile front. No symptoms during STM (any symptoms should be recorded in electronic record to assess association with abnormal motility or function). Slow eating with <200g ingested during 8-minutes also considered abnormal.
Post-Prandial Meal (High-resolution impedance manometry)	Administration of a STM or a self-identified symptom inducing meal followed by extended monitoring (minimum of 10 minutes and occurrence of abnormal activity)	Absence of symptoms and abnormal motility or function during postprandial period. Maximum 4 transient LES relaxations (TLESRs) with belching during initial 10-minutes post-prandial, no volume regurgitation, no rumination or supra-gastric belching episodes.
Pharmacologic Provocation	Amyl Nitrite inhalator (4–5 sniffs) in recumbent position	Profound distal esophageal and LES smooth muscle inhibition with reduction in deglutitive IRP. In healthy controls amyl nitrite-induced EGJ IRP is similar to deglutitive IRP. In patients with a disorder of EGJ obstruction, such as achalasia and true functional EGJOO, amyl nitrite-induced EGJ pressure drop is markedly lower (≥10mmHg) than compromised deglutitive IRP (i.e., relaxation gain). In contrast, amyl nitrite in patients with EGJOO secondary to other factors than LES smooth muscle dysfunction will display little amyl nitrite-induced EGJ pressure change (< 10mmHg).
	Cholecystokinin (CCK) 40ng/kg IV in recumbent position	CCK generally triggers a biphasic esophageal motor response. Phase 1 is always present and starts shortly after injection. In healthy controls, CCK induces a mild esophageal shortening (2cm or less) associated with incomplete EGJ relaxation (inspiratory crural diaphragm contraction preserved). In contrast, CCK in patients with inhibitory dysfunction such as achalasia induces a paradoxical EGJ contraction of more than 50 mmHg.

Distal Contractile Integral (DCI); lower esophageal sphincter (LES); integrated relaxation pressure (IRP); esophago-gastric junction (EGJ); EGJ outflow obstruction (EGJOO)

Classification is based on the primary position in which 10 wet swallows are performed, either supine or upright. Assessment of swallows in the secondary position and with provocation serve as supportive data (with the exception of EGJOO and absent contractility).